09/14/2010

Do We Need a Population Health Super-Integrator?

By David A. Kindig, MD, PhD

In a previous post, I raised the question of who is accountable for population health outcomes, and suggested that some cross-sectoral integrating mechanism might be required. The outside line in the figure below suggests that this mechanism could be that of a Super-Health-Integrator. Such an integrator, with appropriate financial resources and authority, could align investments and activities across the multiple sectors which can impact population health, such as health care, public health, schools, employers, and community organizations.

An alternative to a super-integrator might be that one sector takes lead responsibility for population health improvement, using informal or formal authority to ensure that others play their roles. Regardless of which sector or organization took the lead (this could vary from community to community), the process would likely involve conflict and/or have limited effectiveness. Some concerns would be that healthcare organizations may overemphasize biomedical approaches, that governmental public health is too under-resourced for even its critical traditional functions, and that businesses would be challenged by competing goals. So, I believe that many communities would benefit by having a strong and neutral coordinating entity or mechanism at the helm.

Another alternative is the status quo where each sector makes investments to optimize its own goals, which may or may not include population health improvement. We have ample evidence to show that under this current situation few—if any—communities are as healthy as they could be.

This is why I proposed “health outcomes trusts” in my 1997 book and am proposing Super-Health-Integrators today. To my knowledge nothing like this has been fully developed, although pieces exist in many healthy community partnerships. Such an entity would likely not be governmental or corporate, but would certainly need active public and private sector involvement. And, as noted above, it would need some authority and financial resources to do its work (such as from a redesigned IRS Community Benefit stream). Such Integrators or Trusts might draw on the principles of social entrepreneurship by emphasizing strategic partnerships and leveraging resources to raise levels of performance and accountability (look for the essay by Jane Wei-Skillern in the upcoming issue of Preventing Chronic Disease, available online in mid-October).

I am not naive about the potential challenges such non-traditional structures pose, but the “inconvenient truth” is that addressing the multiple determinants of population health to optimize our communities’ health will almost certainly require some form of coordinating authority. I would love to hear the opinions of others on this point, as well as feature on this blog any examples of existing structures already performing these functions.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

We are beginning to use Triple Aim (TA) principles to improve population health in Hamilton County, Ohio. The local TA team is lsd Cincinnati Children's Hospital Medical Center; thus the medical center initially served as the "super integrator". Progress was too slow, we believed, in part because health care organizations have a primary responsibility for treatment (rather than prevention - a key element of population health improvement) and are ofter suspiciously viewed as self-serving. When we transferred the integrator function to the county commissioners, we felt increased traction, improved pace of improvement and access to public resources such as surveillance. Public health funders (Medicaid, foundations, etc.) are playing increasingly important roles. To date, elected leaders as integrators, at least in Hamilton County, have not been able effectively to bring the private side to the table.
We agree that the "super integrator" function is key, but we have not figured out how to build this.
Seems like we may want to look at a voluntary collaborative of those responsible for allocation of public and private resources?